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Empathy and Osteopathic Medical Education
Leonard Calabrese, D.O.
Mohammadreza Hojat, Ph.D.
David Massello, B.A.
Joseph Bianco, Ph.D.
Douglas Mann, Ph.D.
Ohio University Heritage College of Osteopathic Medicine
The Cleveland Clinic
Jefferson Medical College
Presented at the Annual Meeting of the American Association of Colleges of Osteopathic Medicine
Baltimore, April 2013
Empathy as a Myth
Empathy may not even exist in reality after all (Lane, 1986).
Empathy should be eliminated and replaced by a less
ambiguous term (Levy, 1997).
Empathy is difficult to define and hard to measure
(Kestenbaum et al., 1989).
Empathy as a Reality
A concept that can be operationally
defined and measured cannot be a
myth.
Definition of Empathy in the Context of
Patient Care
Empathy is a predominantly cognitive (rather than emotional) attribute which involves an understanding (rather than feeling) of experiences, concerns, and perspective of the patient, combined with a capacity to communicate this understanding, and an intention to help.”
Hojat, et al., 2002, Am J Psychiatry, 159, 1563-1569.
Hojat, 2007, Empathy in Patient Care, p. 80.
Hojat, et al., 2009, Academic Medicine, 84, 1182-1191.
Measurement of Empathy
in Medical Education and Patient Care
The Jefferson Scale of Empathy
(S-Version, HP-Version, and HPS-Version)
• Contains 20 Likert-type items (7-point scale).
• Data support its validity (construct, criterion-related,
convergent, and discriminant), and reliability (internal
consistency: coefficient alpha; and score stability: test-
retest).
The JSE has been translated into 43 languages so far, and been used in over 60
countries.
Hojat, et al., (2001). Educ & Psych Measurement, 61, 349-365.
Hojat, et al., (2002). Am J Psychiatry, 159, 1563-1569.
SAMPLE ITEMS
From the S-Version:
“It is difficult for a physician to view things from patients’
perspectives.”
From the HP-Version:
“It is difficult for me to view things from my patients’
perspectives.”
From the HPS-Version:
“It is difficult for a health care provider to view things
from patients’ perspectives.”
Selected Highlights of Research Findings
Empathy and Academic Performance
• Empathy scores are significantly correlated with
global ratings of clinical competence in medical
school.
• Empathy scores are not correlated with performance
on objective examination of knowledge in both basic
and clinical sciences.
Hojat, et al., 2002, Med Educ, 36, 522-527.
Physician empathy and gender:
Women in medical school, nursing school,
dental school, and in medical practice tend to
obtain higher empathy scores than men.
Hojat, et al., 2001, Educ & Psych Measurement, 61, 349-365.
Hojat, et al., 2002, Med Educ, 36, 522-527.
Hojat, et al., 2002, Am J Psychiatry, 159, 1563-1569.
Hojat, et al., 2002, Acad Med., 77, s58-s60.
Ward, et al, 2009, J Nursing Measurement, 17, 73-88.
Sherman & Cramer, 2005, J Dental Educ, 69, 338-344.
Physician empathy and specialty:
Physicians in “people-oriented” specialties (e.g.,
psychiatry, family medicine, internal medicine,
pediatrics, obstetrics and gynecology, emergency
medicine, and medical subspecialties) obtained higher
empathy scores than their counterparts in
“technology/procedure-oriented” specialties (e.g.,
anesthesiology, pathology, radiology, surgery and
surgical subspecialties).
Hojat, et al., 2001, Acad Med, 76, 669.
Hojat, et al., 2002, Acad Med, 77, s58-s60.
Hojat, et al., 2002, Am J Psychiatry, 159, 1563-1569.
Physician Empathy and Patient Outcomes
Two key studies In the U.S. and Italy
Physicians' Empathy and Clinical Outcomes for
Diabetic Patients Mohammadreza Hojat, PhD; Daniel Z. Louis, MS; Fred W. Markham, MD;
Richard Wender, MD; Carol Rabinowitz; Joseph S. Gonnella, MD
(Academic Medicine, 2011, 86, 359-364).
Purpose of the study To test the hypothesis that physicians' empathy is
associated with positive clinical outcomes for diabetic
patients.
Data and methods:
891 patients with diabetes mellitus treated by 29
physicians from Jefferson Department of Family and
Community Medicine
100% response rate among the physicians in completing
the Jefferson Scale of Empathy
Physicians were categorized into 3 groups:
high, moderate, and low empathy scorers
Patient outcomes:
Hemoglobin A1c categorized as good control (<7.0%);
poor control (>9.0%)
LDL-C categorized as good control (<100);
poor control (>130)
Primary care physician empathy scores and Hemoglobin A1c
for patients with diabetes mellitus
56% 49%
40%
29% 35%
34%
15% 16% 26%
0%
20%
40%
60%
80%
100%
High empathy Moderate empathy Lower empathy
Poor (> 9.0%)
7.0% - 9.0%
Good (< 7.0%)
Primary care physician empathy scores and
low-density-lipoprotein cholesterol (LDL-C)
for patients with diabetes mellitus
The Relationship Between Physician Empathy and Disease
Complications: An Empirical Study of Primary Care Physicians and
Their Diabetic Patients in Parma, Italy
Stefano Del Canale, MD, PhD; Daniel Z. Louis, MS; Vittorio Maio, PharmD, MS, MSPH; Xiaohong
Wang, MS; Giuseppina Rossi, MD; Mohammadreza Hojat, PhD; Joseph S. Gonnella, MD
(Academic Medicine, 2012, 87, 1243-1249).
Purpose of the Study
To test the hypothesis that scores of a validated measure
of physician empathy are associated with tangible clinical
outcomes for patients with diabetes mellitus.
20,961 patients with type 1 or type 2 diabetes
mellitus.
Enrolled with one of 242 primary care physicians
for the entire year of 2009.
80% response rate.
Patient Outcome: Occurrence of acute metabolic
complications (diabetic ketoacidosis,
hyperosmolar state, coma) in diabetes patients
hospitalized in 2009
Association Between Empathy Scores of Physician
Participants (n = 242) and Disease Complications in
Their Diabetic Patients (n = 20,961) Parma, Italy
Erosion of Empathy in Allopathic Medical Schools
Empathy scores of students in allopathic medical
schools decline significantly during clinical phase of
medical education (third year).
Hojat, et al, Medical Education, 2004, 38, 934-941.
Hojat, et al, Acad Med. 2009, 84, 1182-1191.
Our Empirical Study of Change in Empathy
in Osteopathic Medical Students
• Supported by a grant from the American Osteopathic
Association (AOA).
• Conducted at Ohio University, Heritage College of
Osteopathic Medicine (in 2011-2012 academic year).
• Research participants included 373 medical students.
• Manuscript on major findings is under review by the Journal
of American Osteopathic Association (JAOA)
Research Instruments
1. Jefferson Scale of Empathy (20 items).
2. Jefferson Scale of Attitudes Toward Physician-Nurse
Collaboration (15 items) .
3. Integrative Care Attitude Scale (10 items).
4. A survey on osteopathic experiences prior to medical
school.
Study Participants by Year of Medical School
in 2011-2012 Academic Year
n % women
Year 1 109 47%
Year 2 94 57%
Year 3 101 56%
Year 4 69 51%
Total 373 53%
Osteopathic-Related Experiences Prior to Medical School
• 98% volunteered for medical or community services.
• 93% had observed patient care rendered by osteopathic physicians.
• 53% of students or their family members received medical care from a D.O.
• 12% had a D.O. in their family.
• 12% had received OMT.
Correlations Among Scales
JSE JSAPNC ICAS
JSE1 1.0 .42** .55**
JSAPNC2 1.0 .36**
ICAS3 1.0
**p <.01.
1 The Jefferson Scale of Empathy (JSE).
2 The Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (JSAPNC).
3 Integrative Care Attitude Scale (ICAS).
Mean Scores of the Jefferson Scale of Empathy in
Allopathic and Osteopathic Medical Schools (Cross-Sectional Studies)
Some Specific Features of Osteopathic Medical Education
Which We Speculate Can Promote Empathic Engagement
• Holistic nature of osteopathic medical education?
• Osteopathic manipulative treatment (OMT)?
• Osteopathic apprentice learning model?
• Better role models among clinical faculty?
• Greater interest in primary care (people- oriented)
specialties?
• Greater interest in serving underserved population?
• Less influences by the “hidden Curriculum?”
• Personal characteristics of those who choose osteopathic
medical schools?
• Other factors?
Ongoing Longitudinal Study
of Changes in Empathy in Osteopathic Medical
Students
• We are currently undertaking a longitudinal study to examine
changes in empathy, attitudes toward interprofessional
collaboration, and attitudes toward integrative care.
• A cohort of 78 students who matriculated at Ohio University
Heritage College of Osteopathic Medicine in 2010 are
participants of this longitudinal study.
• We expect to complete this longitudinal study in 2014.
Future Research